Staged Fixation of Tibial Plateau Fractures: Strategies for the Posterior Approach

Abstract

A critical assessment of radiographic and clinical outcomes after complex articular fractures of the proximal tibia demonstrates several aspects worthy of reevaluation and potential modification. These include a refined understanding of fracture pathoanatomy, injury classification, operative exposure, surgical timing, and preferred fixation constructs in addition to implant design modifications. Evolving trends include increasing appreciation of the importance of the fracture morphology in the axial plane and the role that the fracture pattern has on the choice of surgical approach. This focused review will highlight the attributes and limitations of classification schemes (both conventional and contemporary) as well as the role that posterior surgical approaches performed in the prone position may offer in select clinical scenarios. The merits of staged fixation (prone followed by supine patient positioning), its technique, indications, and potential liabilities are described and case examples offered.

Keywords

staged - posterior - plateau - Lobenhoffer

• References

• 1 Watson JT. High-energy fractures of the tibial plateau. Orthop Clin North Am 1994; 25 (4) 723-752
• 2 Lowe JA, Tejwani N, Yoo BJ, Wolinsky PR. Surgical techniques for complex proximal tibial fractures. Instr Course Lect 2012; 61: 39-51
• 3 Streubel PN, Glasgow D, Wong A, Barei DP, Ricci WM, Gardner MJ. Sagittal plane deformity in bicondylar tibial plateau fractures. J Orthop Trauma 2011; 25 (9) 560-565
• 4 Morris BJ, Unger RZ, Archer KR, Mathis SL, Perdue AM, Obremskey WT. Risk factors of infection after ORIF of bicondylar tibial plateau fractures. J Orthop Trauma 2013; 27 (9) e196-e200
• 5 Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK. Complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. J Orthop Trauma 2004; 18 (10) 649-657
• 6 Colman M, Wright A, Gruen G, Siska P, Pape HC, Tarkin I. Prolonged operative time increases infection rate in tibial plateau fractures. Injury 2013; 44 (2) 249-252
• 7 Xu YQ, Li Q, Shen TG, Su PH, Zhu YZ. An efficacy analysis of surgical timing and procedures for high-energy complex tibial plateau fractures. Orthop Surg 2013; 5 (3) 188-195
• 8 Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 2005; 19 (7) 448-455 , discussion 456
• 9 Zhu Y, Hu CF, Yang G, Cheng D, Luo CF. Inter-observer reliability assessment of the Schatzker, AO/OTA and three-column classification of tibial plateau fractures. J Trauma Manag Outcomes 2013; 7 (1) 7
• 10 Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma 2010; 24 (11) 683-692
• 11 Zhu Y, Yang G, Luo CF , et al. Computed tomography-based Three-Column Classification in tibial plateau fractures: introduction of its utility and assessment of its reproducibility. J Trauma Acute Care Surg 2012; 73 (3) 731-737
• 12 Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H. Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures [in German]. Unfallchirurg 1997; 100 (12) 957-967
• 13 Galla M, Lobenhoffer P. The direct, dorsal approach to the treatment of unstable tibial posteromedial fracture-dislocations [in German]. Unfallchirurg 2003; 106 (3) 241-247
• 14 Galla M, Riemer C, Lobenhoffer P. Direct posterior approach for the treatment of posteromedial tibial head fractures [in German]. Oper Orthop Traumatol 2009; 21 (1) 51-64
• 15 Bhattacharyya T, McCarty III LP, Harris MB , et al. The posterior shearing tibial plateau fracture: treatment and results via a posterior approach. J Orthop Trauma 2005; 19 (5) 305-310
• 16 He X, Ye P, Hu Y , et al. A posterior inverted L-shaped approach for the treatment of posterior bicondylar tibial plateau fractures. Arch Orthop Trauma Surg 2013; 133 (1) 23-28
• 17 Fakler JK, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR. Optimizing the management of Moore type I postero-medial split fracture dislocations of the tibial head: description of the Lobenhoffer approach. J Orthop Trauma 2007; 21 (5) 330-336
• 18 Brunner A, Honigmann P, Horisberger M, Babst R. Open reduction and fixation of medial Moore type II fractures of the tibial plateau by a direct dorsal approach. Arch Orthop Trauma Surg 2009; 129 (9) 1233-1238
• 19 Barei DP, O'Mara TJ, Taitsman LA, Dunbar RP, Nork SE. Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. J Orthop Trauma 2008; 22 (3) 176-182
• 20 Higgins TF, Kemper D, Klatt J. Incidence and morphology of the posteromedial fragment in bicondylar tibial plateau fractures. J Orthop Trauma 2009; 23 (1) 45-51
• 21 Weaver MJ, Harris MB, Strom AC , et al. Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures. Injury 2012; 43 (6) 864-869
• 22 Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK. Functional outcomes of severe bicondylar tibial plateau fractures treated with dual incisions and medial and lateral plates. J Bone Joint Surg Am 2006; 88 (8) 1713-1721
• 23 Weil YA, Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Posteromedial supine approach for reduction and fixation of medial and bicondylar tibial plateau fractures. J Orthop Trauma 2008; 22 (5) 357-362
• 24 Potocnik P, Acklin YP, Sommer C. Operative strategy in postero-medial fracture-dislocation of the proximal tibia. Injury 2011; 42 (10) 1060-1065
• 25 Stark E, Stucken C, Trainer G, Tornetta III P. Compartment syndrome in Schatzker type VI plateau fractures and medial condylar fracture-dislocations treated with temporary external fixation. J Orthop Trauma 2009; 23 (7) 502-506
• 26 Watson JT, Boudreau JA, Karges D, Kuldjanov D. Staged Treatment for Complex 3 Column Tibial Plateau Fracture Dislocations. Paper presented at: Annual Meeting of the American Academy of Orthopedic Surgeons; March 11, 2014; New Orleans, LA. Paper 084
• 27 Kottmeier SA, Jones CB, Tornetta III P, Russell TA. Locked and minimally invasive plating: a paradigm shift? Metadiaphyseal site-specific concerns and controversies. Instr Course Lect 2013; 62: 41-59
• 28 Higgins TF, Klatt J, Bachus KN. Biomechanical analysis of bicondylar tibial plateau fixation: how does lateral locking plate fixation compare to dual plate fixation?. J Orthop Trauma 2007; 21 (5) 301-306
• 29 Yoo BJ, Beingessner DM, Barei DP. Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods. J Trauma 2010; 69 (1) 148-155
• 30 Chang SM, Wang X, Zhou JQ, Huang YG, Zhu XZ. Posterior coronal plating of bicondylar tibial plateau fractures through posteromedial and anterolateral approaches in a healthy floating supine position. Orthopedics 2012; 35 (7) 583-588